چکیده انگلیسی

Two experiments were conducted to examine the link between safety behaviors and social judgments in social anxiety disorder (SAD). Safety behaviors were manipulated in the context of a controlled laboratory-based social interaction, and subsequent effects of the manipulation on the social judgments of socially anxious participants (N = 50, Study 1) and individuals meeting diagnostic criteria for generalized SAD (N = 80, Study 2) were examined. Participants were randomly assigned to either a safety behavior reduction plus exposure condition (SB + EXP) or a graduated exposure (EXP) control condition, and then took part in a conversation with a trained experimental confederate. Results revealed across both studies that participants in the SB + EXP group were less negative and more accurate in judgments of their performance following safety behavior reduction relative to EXP participants. Study 2 also demonstrated that participants in the SB + EXP group displayed lower judgments about the likelihood of negative outcomes in a subsequent social event compared to controls. Moreover, reduction in safety behaviors mediated change in participant self-judgments and future social predictions. The current findings are consistent with cognitive theories of anxiety, and support the causal role of safety behaviors in the persistence of negative social judgments in SAD.

مقدمه انگلیسی

Individuals with Social Anxiety Disorder (SAD) tend to make overly-negative judgments about themselves and social events (e.g., Alden and Wallace, 1995, Foa et al., 1996 and Rapee and Lim, 1992; see Hirsch & Clark, 2004 for a review). Cognitive theorists propose that these judgmental biases perpetuate social anxiety and avoidance (e.g., Clark, 2001, Clark and Wells, 1995, Hofmann, 2007 and Rapee and Heimberg, 1997). In support of that reasoning, reductions in judgmental biases have been found to mediate symptom improvement in patients with SAD (Foa et al., 1996, Hofmann, 2004, Smits et al., 2006 and Taylor and Alden, 2008). Identifying the factors that maintain judgmental biases is therefore of potential value in validating theoretical models and enhancing treatments for SAD.
According to cognitive writers, one such contributing factor is reliance on safety (subtle avoidance) behaviors (e.g., Clark and Wells, 1995 and Rapee and Heimberg, 1997). Safety behaviors are covert and overt actions adopted by the individual to prevent feared outcomes and maintain a sense of safety. Instead, these actions are hypothesized to impede assimilation of accurate information about social events, the end result of which is to maintain judgmental biases and therefore, social anxiety. Despite their theoretical prominence, relatively little research has examined the causal link between safety behaviors and the maintenance of judgmental biases in SAD populations. Here, we report two studies that used controlled laboratory methods to evaluate whether safety behaviors displayed the hypothesized causal relationship with judgmental biases in an ecologically valid social situation.
Cognitive theorists propose that SAD is maintained through a chain of cognitive–emotional processes that involve negative judgments prior to and during social events. According to these models, socially anxious individuals make negative predictions about the likely outcomes of social events (e.g., Clark and Wells, 1995, Hofmann, 2007 and Rapee and Heimberg, 1997). These predictions are hypothesized to produce anticipatory anxiety and lead to selective processing of threat-related cues. The increased salience of threat information skews interpretations of the event so that these individuals make overly-negative judgments about their performance and others' reactions to them. These biased interpretations then contribute to negative predictions for subsequent events, thereby establishing a self-perpetuating cycle that maintains social fear and avoidance (Clark and Wells, 1995 and Rapee and Heimberg, 1997). In support of this perspective, individuals with SAD have been shown to overestimate the likelihood and cost of negative social outcomes (e.g., Foa et al., 1996, Gilboa-Schechtman et al., 2000 and Wilson and Rapee, 2005). Following social events, they tend to overestimate how anxious they appeared and underestimate others' responses to them (e.g., Alden and Wallace, 1995, Rapee and Lim, 1992, Stopa and Clark, 1993 and Taylor and Alden, 2005; see Hirsch & Clark, 2004 for a review). Moreover, such judgmental biases tend to persist even in the face of evidence to the contrary, i.e., positive social outcomes (e.g., Wallace & Alden, 1997).
Cognitive writers speculate that reliance on safety behaviors maintains judgmental biases by preventing assimilation of threat-inconsistent information, either because attention and cognitive resources are preferentially allocated to safety behavior execution instead of the event itself (e.g., Rapee and Heimberg, 1997 and Sloan and Telch, 2002) or because the individual believes that the actions prevented the feared outcome (e.g., Salkovskis, 1991). While the construct of safety behaviors is a key aspect of cognitive SAD models, empirical studies are sparse. McManus, Sacadura, and Clark (2008) found that socially anxious individuals reported using a larger number of safety behaviors, more frequently, and in a greater variety of situations than individuals low in social anxiety (see also Cuming et al., 2009). Moreover, these individuals perceived their safety behaviors to be beneficial in reducing the likelihood of negative social outcomes. In addition, several studies found that socially anxious individuals relied more on self-protective behaviors in response to social threat (Alden and Bieling, 1998 and DePaulo et al., 1990).
Four studies experimentally manipulated safety behaviors. Using a case-controlled experimental design with eight SAD patients, Wells et al. (1995) found that encouraging patients to reduce safety behaviors during exposure to idiosyncratic feared situations significantly reduced patients' belief that their feared outcome had occurred compared to exposure alone. Kim (2005) replicated those findings in students with SAD and, in addition, demonstrated that the effectiveness of eliminating safety behaviors was enhanced by a rationale highlighting prediction disconfirmation. These studies suggest that safety behaviors may contribute to the maintenance of idiosyncratic fear-relevant beliefs (e.g., Clark and Wells, 1995 and Salkovskis, 1991). McManus et al. (2008) compared the judgments of participants high in social anxiety during a conversation with a stranger under two conditions; when they were instructed to focus on themselves and to engage in a list of safety behaviors commonly reported by individuals with SAD versus when they were instructed to focus externally and not use any of the scripted safety behaviors. Results revealed that participants were more likely to overestimate their visible anxiety when instructed to self-focus and engage in the safety behaviors. Comparable findings were obtained by McManus et al. (2009) who used a similar experimental procedure in the context of a cognitive therapy program for patients with SAD. Because the manipulation in these studies combined instructions about focus of attention with adopting safety behaviors, however, the unique effect of safety behaviors on self-judgments was not clear.
Although the results of extant studies are consistent with the hypothesis that safety behaviors are associated with dysfunctional beliefs and negative judgments, no research has manipulated the idiosyncratic safety behaviors of SAD patients and examined corresponding effects on biases in social judgments and predictions. In addition, empirical support for the causal status of safety behaviors is weakened by failure to assess whether experimental manipulations reduced safety behaviors as intended (see Kim, 2005 for an exception). Thus, it remains unclear whether safety behaviors per se were responsible for the observed cognitive changes. Finally, cognitive theories of SAD argue that safety behaviors can elicit negative social responses from others (e.g., Alden and Taylor, 2004, Clark, 2001 and Clark and Wells, 1995). These findings underscore the importance of controlling for differences in the behavioral responses of others that may arise from differential safety behavior use. Because previous research has not always maintained control over the social environment, identifying the source of safety behavior effects on social judgments is obscured. All in all, confidence in the proposed causal link between safety behaviors and the maintenance of judgmental biases would strengthened by research that firmly establishes the effects of experimental manipulations of idiosyncratic safety behaviors in a controlled social environment.